A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Rationale

Interpretation of Actions:

• Encourage the client to cough:
  • Nonessential
    Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
• Initiate seizure precautions:
  • Anticipated
    Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
• Elevate the head of the bed:
  • Anticipated
    Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
• Keep the client's head in a midline position:
  • Anticipated
    Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
• Decrease oxygen to 1.5 L/min via nasal cannula:
  • Contraindicated
    Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
• Assist the client to the bathroom:
  • Contraindicated
    Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.

A. A low pressure alarm on the ventilator often indicates a leak in the system, which can be due to a cuff leak in the endotracheal tube or tracheostomy. The nurse should evaluate for a cuff leak or other issues that may be causing the air to escape.

B. While water in the ventilator tubing can cause a high pressure alarm, it is less likely to trigger a low pressure alarm. Emptying the water from the tubing may be necessary but is not the first priority in this situation.

C. Increasing the ventilator flow rate is not an appropriate response to a low pressure alarm. The problem is likely a leak, and addressing the leak is more important than adjusting the flow rate.

D. Suctioning the client's airway may be necessary if the client has secretions that are obstructing the airway, but it is not the first intervention for a low pressure alarm. The primary concern should be checking for a leak or disconnection.